Provider Demographics
NPI:1629075957
Name:MANSFIELD, LINDA A (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:A
Last Name:MANSFIELD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 W JEFFERSON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1993
Practice Address - Country:US
Practice Address - Phone:574-647-1669
Practice Address - Fax:574-239-6461
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2023-04-28
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
IN01069249A207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000713021OtherBCBS BMG SPORTS MEDICINE
INP00955365OtherRR MEDICARE
IN201020040Medicaid
IN000000714060OtherBCBS BMG SPORTS MEDICINE SB
INP00955365OtherRR MEDICARE
IN000000713021OtherBCBS BMG SPORTS MEDICINE
IN000000714060OtherBCBS BMG SPORTS MEDICINE SB
OH4028342Medicare PIN
IN201020040Medicaid
OH2986729Medicaid